10/1/09: Massachusetts as a model Andrew D. Coates, MD, secretary of the capital district chapter of Physicians for a National Health Program (pnhp.org), teaches medical students and residents at Albany Medical College and practices internal medicine in Albany, NY. 8/5/09: Single payer to be introduced on the floor of the U.S. House of Representatives Last week the House Energy and Commerce Committee passed HR 3200 the major health reform legislation that will come before the House of Representatives this fall. On the last night of the markup of the bill, Congressman Anthony Weiner, who represents neighborhoods in Brooklyn and Queens, placed an amendment before the Energy and Commerce Committee to replace the text of HR 3200 with the text of HR 676, the United States National Health Care Act, the single payer bill with 86 House co-sponsors. Weiner was joined by fellow Energy and Commerce committee members Peter Welch of Vermont, Mike Doyle of Pennsylvania, Tammy Baldwin of Wisconsin, Jan Schakowsky and Bobby L. Rush of Illinois and Eliot L. Engel of New York. After each spoke about the need for single payer health reform, committee Chairman Henry Waxman interrupted Representative Weiner to say that House Speaker Nancy Pelosi had promised that single payer legislation would come before the entire House of Representatives -- if the Congressman would agree to withdraw the amendment from the committee. "The Speaker has said that she will allow this to be brought up on the House floor, and debated, and voted on," Waxman said. When the committee chairman interrupted him, Representative Weiner looked surprised, but kept his composure, asked the Chairman to reiterate the offer, and heartily accepted the deal. Energy and Commerce was the last of 3 House committees to pass the bill put forward by the Democratic leadership. The 3 versions of HR 3200 will now be merged and go before the House in the fall. The timing of the House vote will have a lot to do with events in the Senate, where the Senate Finance Committee has yet to debate a bill. Representative Weiner hailed the victory in a brief statement: "Single-payer is a better plan and now it is on center stage," Weiner said. "Americans have a clear choice. Their Member of Congress will have a simpler, less expensive and smarter bill to choose. I am thrilled that the Speaker is giving us that choice." Early this year Senate Finance Committee Chair Max Baucus, the Montana Democrat who has reportedly taken more money from health and insurance industry interests than any other member of Congress, delcared that single payer was "off the table." Is it surprising that the speaker of the House would allow single payer to go from "off the table" to the floor of the House of Representatives, where it will be the only alternative to the bill that has gone through the three committees of jurisdiction? Back in April, Nancy Pelosi said "In our caucus, over and over again, we hear single payer, single payer, single payer. Well," she added, "it’s not going to be a single payer." Chairman Waxman was a cosponsor of the single payer bill in the 109th Congress. Nancy Pelosi has supported single payer in the past also. They know the proposal well. A strong single payer vote this fall may help the Speaker reign in reluctant Blue Dogs and back down Republicans. All year long the single payer movement has grown. By allowing the proposal to be debated and defeated on the House floor, will the Democratic leadership "move on" or will the tempo and volume of the single payer movement increase further? Anthony Weiner’s initiative has yielded an historic step for the cause of a single payer program to finance health care in the United States. It is also a measure of the success of a growing grassroots movement. Andrew D. Coates, MD, secretary of the capital district chapter of Physicians for a National Health Program (pnhp.org), teaches medical students and residents at Albany Medical College and practices internal medicine in Albany, NY. 5/1/09: About those Canadian wait times In 2005 the Supreme Court of Canada ruled that the province of Quebec could not bar private health insurance from covering the same services as the province's single payer system, if Canada's Medicare made patients wait. The case was brought by Dr. Jacques Chaoulli on behalf of his patient who had waited one year for an elective hip replacement surgery. A crusader for privatization of medical care, Dr. Chaoulli argued that the public system of health care financing caused Canadians to "suffer and die" while waiting for treatments. The Supreme Court of Canada found that waiting for surgery was a violation of the patient's human rights. The province of Quebec, in turn, passed a law to allow the sale of private insurance to cover three specific elective surgeries that had wait lists: hip and knee replacement and cataract surgeries. Thanks to his crusade against the Canadian single payer system Dr. Chaoulli became the darling of the insurance industry and well-funded ideologues hired to champion profiteering at the expense of the sick. He even inspired a few free-market fundamentalists to seek constitutional grounds to abolish Medicare in the United States. Other free-market enthusiasts also took up Dr. Chaoulli's cry that Canadians would get seen more quickly and receive better care, if only they were allowed to pay privately. If only. Jean-Jacques Sauvageau died in the waiting room of a private clinic in Quebec in January 2008. The clinic advertised emergency care. The subsequent investigation has led the provincial coroner to urge the Quebec College of Physicians to issue guidelines to protect patient safety at private clinics. The physician on duty at the private clinic was Dr. Jacques Chaoulli. The clinic's receptionist (who had no medical training) took identifying information and asked Mr. Sauvageau to take a seat. The coroner reported that Mr. Sauvageau then waited 20 to 60 minutes, blue and gasping, his shoulders heaving with each breath. In the Globe and Mail Ingrid Peritz described his death as "a scene that combined tragedy with Monty Python farce. She wrote, " ...the increasingly alarmed fellow patients could see Mr. Sauvageau was unconscious and alerted the receptionist. Dr. Chaoulli came out, did a cursory examination and concluded the patient was already dead. He left him sitting in the chair, and told the nurse to phone 911 to report the death. But the 911 operator pleaded with the nurse to try to revive Mr. Sauvageau. Dr. Chaoulli got on the phone and tried to argue the patient was dead; however, the 911 operator insisted... Eventually, ambulance medics arrived and tried in vain to revive the patient. An autopsy later revealed that Mr. Sauvageau died of a pulmonary embolism and would not have survived anyway. But the coroner said that Dr. Chaoulli had no way of knowing that, and should have tried to perform CPR..." The Globe and Mail story concludes, "Michel Sauvageau, the victim's son, said the family was still appalled by his father's treatment..." "An animal at a veterinarian's clinic gets better treatment than my father got," Michel Sauvageau told the Globe and Mail. This case has deepened the debate over the privatization of Canada's Medicare, for the tragedy demonstrates why medical services cannot depend upon the 'irrational exuberance' of the "free market." One Canadian blogger, Mary Soderstrom, politely observed: "Certainly in this case it doesn’t look like Chaoulli’s clinic provided the kind of excellent health care proponents of privatization vaunt... what would have happened had he gone to a hospital emergency room where triage teams are trained to quickly size up a situation. It’s doubtful that a man turning blue would be told to sit and wait on a chair: while there's no doubt that it can take hours for non-urgent cases to be seen, Sodertrom concludes, life-threatening cases are evaluated and treated quickly in hospitals." Mr. Sauvageau's death reminds us that a person in acute distress, or a person in need of a surgery or care in general, is in no position to predict what care will be required. What kind of society would take the health and illness of human beings as an occasion to shop for a bargain -- or a money-making moment for profiteers? Health policies and budgets are best set by the public. The effort to reduce waiting times is no exception. Last week the Wall Street Journal reported that, thanks to layoffs, 9 million people have lost their employer-sponsored private health insurance in the United States in the last year. This week more uninsured patients strain hospital budgets, many hospitals report fewer inpatient admissions overall, the Wall Street Journal reports. For example, 41% of hospitals reported a moderate decrease in elective procedures, and 18% said the decrease was significant. During the same period in Canada, including Quebec, waiting times for elective procedures have improved. Ironically, Dr. Chaoulli's lawsuit has strengthened the single payer system. As a result, Dr. Randall White of the Canadian Doctors for Medicare points out that no one in Quebec has purchased the new private health insurance. Not one. This is from a CBC News report: More than two years after Quebec legalized private medical coverage for select surgeries, the insurance industry says it has not sold a single policy. Quebec Health Minister Yves Bolduc said the province has sped up wait times so much since the court ruling, it's no wonder no one wants to pay for private coverage. "We have such a good access to the surgeries in Quebec, that the industry knows they won't be able to sell any insurance to anybody," Bolduc told the CBC. Imagine that. The province of Quebec, with its health system underfunded and in spite of a growing global economic crisis, has successfully shortened wait times for elective surgeries. Meanwhile in the United States elective surgery is increasingly "off the table" for the uninsured and under-insured. In addition the New York Times reported in March 2009 that more than 85,000 people leave the United States each year, to travel to other countries for elective surgeries. In the waiting room of a private clinic that advertised emergency care, the tragedy that befell Mr. Sauvageau, and indeed Dr. Chaoulli, emphasizes our need for public decision-making, public financing and public health services. In the United States and Canada, as in every country, decisions over how best to share health resources belong in the public domain. In Canada we must defend Medicare against privatization. In the United States we need to enact a single payer national health program. Single payer is not a perfect system, but it is so much better than the alternative, privatization and profiteering at the expense of the sick. An expanded version of this commentary, with links, is available at www.pnhp.org/blog/2009/04/30/akin-to-the-scene-of-a-crime/ Andrew D. Coates, MD, secretary of the capital district chapter of Physicians for a National Health Program (pnhp.org), teaches medical students and residents at Albany Medical College and practices internal medicine in Albany, NY. 2/23/09: Subsidizing COBRA is not enough - We need Single Payer COBRA is a law that allows you to keep your employer-sponsored health insurance for 18 months if you lose or change jobs. To do so, you have to pay 102% of the cost (the full premium plus a 2% surcharge.) The stimulus package just passed provides for laid off workers, who had health insurance on the job, to receive a subsidy of 65% of the health insurance premium for up to nine months. According to a report by FamiliesUSA, the national average unemployment benefit is $1,278 monthly. Under COBRA, national family coverage averages $1,069 per month. So laid off workers, in order to keep health insurance for their families, will have to pay more than $375 a month but after nine months will have to come up with the full $1,069. Here in New York, to keep family health insurance under COBRA costs an average of $13,618 a year, 85% of the average unemployment benefit in New York. For those eligible in New York, the 9-month COBRA subsidy will lower the the average cost for a family to keep health insurance to about $7,000 for a full year. The family also gets to keep the out-of-pocket expenses -- co-pays, co-insurance and deductibles. A recent study by the Commonwealth fund reported that only 9% of unemployed workers continued health insurance under COBRA. The 65% subsidy should allow some to consider keeping health insurance under COBRA, where before it would have been just unthinkable. This can help those with chronic illnesses, or those with very sick family members, or where a spouse continues working. To keep family coverage under COBRA, with the subsidy, for up to nine months, it will cost people who are laid off, on average, one-third of every unemployment check. This money will go to a health insurance company, instead of food, housing and school expenses for the family. But while the subsidy makes private health insurance through COBRA slightly more affordable for the unemployed, purchasing it remains a Faustian bargain. What “stimulus” is there in asking a person who has just lost their job to give a third of each unemployment check to the private insurance industry? And what will they do after nine months have come and gone? Despite the good intentions in Congress and the White House, subsidized COBRA payments are not feasible for the unemployed -- and terrible policy for the nation. There is no reason on why Congress should shovel our money into an industry that pits its profits against our health, with a program that holds one-third of our limited unemployment check hostage and only lasts nine months. If the leaders of this nation wanted to provide health security for all they would enact a single-payer mechanism to finance health care. Single payer would mean that no one would ever be without health care. Not first time job seekers, not workers changing jobs, not laid off or striking workers. Everyone would be covered. A single payer health program would: -- save at least $400 billion in health spending per year, -- create millions of new jobs, -- create enormous savings for employers (including federal, state and local governments as well as schools and not-for-profit agencies) who now pay private health insurance premiums, -- allow the unions to get back to bargaining for wages and working conditions instead fighting over premiums, co-pays, deductibles, co-insurance payments, dental, vision, drug coverage, mental health benefits, etc.-- and, in relieving the worry about health coverage that comes with the loss of a job, single payer would raise us all up. Now that would be a stimulus! We really need single payer national health care. Andrew D. Coates, MD, secretary of the capital district chapter of Physicians for a National Health Program (pnhp.org), teaches medical students and residents at Albany Medical College and practices internal medicine in Albany, NY. 2/12/09: A visit to the Lincoln Memorial In a beautiful essay on Lincoln last month, Eric Foner begins: “Abraham Lincoln has always provided a lens through which Americans examine themselves.” http://www.ericfoner.com/articles/012609nation.html Last year we met my brother’s family in Washington, DC. One day we all walked from the Capitol to the Lincoln Memorial. Climbing the steps, our oldest pointed to where Martin Luther King, Jr. spoke during the March on Washington in 1963. Did he he remember the story of an outdoor concert before the Second World War, by the great African-American singer Marian Anderson, who had been excluded from performing in Constitution Hall? He did. “That was here too?” A worthy test of public architecture might be whether it makes young children giddy and eager to skip and run. Walking along the reflecting pool toward the Lincoln Memorial did that. But when we entered the Lincoln Memorial the children’s liberated mood turned to solemn awe. They grew quiet. Our youngest craned her neck. Our oldest, usually eager to share his thoughts, grew hushed as he silently read the inscriptions and absorbed the great statue. What did Harriet, our middle child know of detail – or the enormity – of the American Civil War, of Lincoln’s role in history? Now where was Harriet? We found her sitting quietly on the floor facing the north wall of the monument, reading the text of Lincoln’s Second Inaugural Address. I read over her shoulder. Lincoln said: “…all thoughts were anxiously directed to an impending civil-war. All dreaded it -- all sought to avert it. ... Both parties deprecated war; but one of them would make war rather than let the nation survive; and the other would accept war rather than let it perish. And the war came...” In Harriet’s view war seemed to be a choice that men make. I wondered if she would accept the idea that history could make war inevitable. I recalled the enormity of the war, 4 million people fought and over 600,000 lives were lost. Lincoln continued: “…slaves constituted a peculiar and powerful interest. All knew that this interest was, somehow, the cause of the war...” Harriet saw slavery as a great evil. “People should never do that,” she had said. She also had begun to see that although in 1865 slavery had been defeated, racism persists. Once when the subject of reparations, compensation for the descendants of those enslaved in America came up – probably thanks to public radio – Harriet asked what it was all about. She paused a moment. “That would be fair.” Did she know that African-Americans joined the Union Army by the thousands after the Emancipation Proclamation? But here again was Lincoln: “Fondly do we hope -- fervently do we pray -- that this mighty scourge of war may speedily pass away. Yet, if God wills that it continue, until all the wealth piled by the bond-man's two hundred and fifty years of unrequited toil shall be sunk, and until every drop of blood drawn with the lash, shall be paid by another drawn with the sword, as was said three thousand years ago, so still it must be said "the judgments of the Lord, are true and righteous altogether."” What might a child make of the complex process through which Lincoln changed himself? In 1861 he still recoiled from the example set by John Brown, but by the Second Inaugural Address Lincoln referred to Sherman’s March to the Sea, the ruthless campaign that devastated Georgia and broke the power of the slave-owning class, as “reasonably satisfactory and encouraging to all.” Lincoln had come, by inches, to understand the war as inescapable as it was just. But my meditation on Lincoln ended as Harriet jumped up to explore with her siblings and cousins. Quickly I gathered the scene in memory. This week Harriet told us about a classroom discussion about Abraham Lincoln. She had raised her hand to make the observation that without Lincoln, Barack Obama might not have become President. (I guess we’d have McCain then, she added.) I asked Harriet if she remembered sitting on the floor of the Lincoln Memorial last year. “Sure.” How did it make you feel? “Like I was part of history. And that it is wrong to treat people differently. Everyone should be treated the same.” What do you think about Lincoln? “I think that Lincoln believed in freedom, no matter what. He had to make a war. And he really wanted peace.” My goodness, Harriet. As Lincoln concluded his Second Inaugural: “With malice toward none; with charity for all; with firmness in the right, as God gives us to see the right, let us strive on to finish the work we are in; to bind up the nation's wounds; to care for him who shall have borne the battle, and for his widow, and his orphan to do all which may achieve and cherish a just, and a lasting peace, among ourselves, and with all nations.” Although the conditions of Lincoln’s time created the need for a great and revolutionary leader, Lincoln made himself into that leader. Eric Foner concluded his essay: “Lincoln was asking Americans to confront unblinkingly the legacy of bondage and to think about the requirements of justice.” That sentiment is very close to what we brought back with us from our visit to the Lincoln Memorial. Andrew D. Coates, MD, secretary of the capital district chapter of Physicians for a National Health Program (pnhp.org), teaches medical students and residents at Albany Medical College and practices internal medicine in Albany, NY. 2/09/09: Stimulate the roots! Who ever thought that a massive blank-check bailout for Wall Street wizards was a good idea? 77 years ago, when Herbert Hoover tried to loosen frozen credit in a similar way, a critic wagged that he was fertilizing the leaves instead of the roots. Last week New York Comptroller Thomas DiNapoli revealed that Wall Street finance executives took home $18.4 billion in personal bonus compensation in 2008, on the heels of an astronomical government bailout for their failed industry. The popular response intoned another word for fertilizer. But what kind of stimulus would feed the roots? Let’s consider the G.I. Bill of 1944, the last act of the New Deal. Enacted in expectation of the return of the veterans of the Second World War, it subsidized full tuition, plus fees, books and education expenses, allowing veterans to attend the college or a training program of their choice, providing they met admission requirements. It guaranteed no-down-payment low-interest home loans. The G.I. Bill offered the famous "52-20 club" -- $20 a week for up to 52 weeks for unemployed veterans, so veterans would have some breathing space after the war, instead of taking whatever job came along. Elevating the G.I. Bill was a sincere fear of a post-war depression, the ideas of John Maynard Keynes and the enormous profits of the war industries. A bipartisan effort, the first draft was written by a man who had been Chairman of the Republican Party and national commander of the American Legion. But the most decisive impetus behind the G.I. Bill was grassroots action that started more than a decade earlier. In the summer of 1932, during the presidential campaign between Hoover and FDR, the "Bonus Army," 60,000 World War I veterans, their families, friends and supporters, Black and white, protested in Washington, DC to demand early payment of compensation promised in 1945 as a form of unemployment relief. The House of Representatives voted to grant the bonus but the Senate rejected it. Ten thousand veterans, one-fifth of them disabled, joined also by their families, continued the protest from a large “Hooverville” of tents and shacks. President Hoover dispatched the U.S. Army. General MacArthur, Colonel Eisenhower and Major Patton led the cavalry, tanks and tear gas, to rout and raze the unarmed encampment. Local hospitals were swamped and two babies subsequently died. Radio and newspaper reports and newsreel footage stoked outrage. FDR, here in Albany, understood the significance of public sentiment. "Well," he said, “this elects me.” In 1933 the Bonus Army returned to Washington to protest. Even though President Roosevelt had, like Hoover, no intention of supporting their demands, he sent his wife Eleanor and a top aide down to the crowd to speak with the protesters in person. Eleanor signed veterans up for work relief programs. Two years later a deadly hurricane struck the Florida Keys, killing 248 veterans working on the kind of public relief project like the ones Eleanor Roosevelt had promoted. Sympathy for the veterans was aroused again – and in 1936 the Senate joined the House of Representatives to grant the early payment of the veterans’ “bonus.” Even so, FDR vetoed it. Due to overwhelming grassroots pressure, Congress overrode him. In 1944 with the Bonus Army and the hardships of a decade earlier still fresh in memory, passage of the G.I. Bill became a great urgency. Ultimately nearly half of the 16 million veterans of the Second World War went to colleges, universities and training programs. Hundreds of millions more lives were changed for the better, including my own. One of my greatest teachers would not have become a professor without the G.I. Bill. Supporting higher education remains an important way to stimulate our economy and improve our society. The multiplier effect is large. For example, the State University of New York reports that for every state dollar SUNY receives, $8 in total spending results in New York State. In terms of higher education, what could New York do with, say, an $18.4 billion bonus? Why it would pay tuition for all students of SUNY and CUNY and the community colleges ten times over! In the face of a worsening depression we need stimuli that will work from the bottom up. But we also need to remember the Bonus Army: only grassroots action can bring meaningful change. Andrew D. Coates, MD, secretary of the capital district chapter of Physicians for a National Health Program (pnhp.org), teaches medical students and residents at Albany Medical College and practices internal medicine in Albany, NY. 1/30/09: FDR's Footfalls Echo in 2009 Footfalls echo in the memory Down the passage which we did not take Towards the door we never opened Into the rose-garden. -- T.S. Eliot, "Burnt Norton," 1935 (from Four Quartets) The official images of a seamless transition between Presidents Bush and Obama invite contrast with the inauguration Franklin Delano Roosevelt 76 years ago, when mutual disdain shaped the day. By the end of his term Herbert Hoover was the most unpopular President of the United States. Perhaps only George W. Bush, today, might know how he felt. On the other hand, Hoover never had a reporter throw shoes at him during a press conference. Two weeks before the 1933 inauguration, as bank failures spread, Hoover had the Secret Service deliver a handwritten letter. “I am convinced,” he wrote to FDR, “that a very early statement by you upon two or three policies of your administration would serve greatly to restore confidence and cause a resumption of the march of recovery. The large part which fear and apprehension play in the situation can be well demonstrated by repeated experience." Hoover knew that Roosevelt could engender optimism. Hoover, in his focus on the role of public confidence, foreshadowed one of his rival’s most famous lines, the one about "fear itself." Yet we also know that the outgoing President wanted to get FDR on the public record in support of his own initiatives. FDR would have none of it, and Hoover thought him a madman. Yet FDR keenly understood the profound desire for change among the people. He used the transition period to prepare to cement his popularity – and Hoover’s unpopularity. He seized the inauguration as part of the political theater of a new beginning. Hoover and FDR also cultivated personal animosity. Hoover, it seems, did not think a paraplegic fit to be president. And FDR, it seems, adduced as much from their few interactions. So FDR did not respond to Hoover’s letter, pretending later that his secretary had lost his dictation. As they rode together from the White House to the Capitol for the inauguration, the nation in crisis, the banking system collapsed in 34 of 48 states, Hoover would not even speak to Roosevelt. And FDR made no reference to Hoover in his address. What a contrast the transition from Bush to Obama! At the start his address, President Obama thanked Bush “for his service to our nation, as well as the generosity and cooperation he has shown throughout this transition.” Someday we might learn of concealed backstage tensions. There was Bush, yucking it up as Obama walked him to the departing helicopter. Almost immediately Bush's closest advisors, Karen Hughes and Karl Rove put on display their petulance toward Obama, while aboard Bush’s airplane back to Texas. But overall Bush and Obama achieved a cordial public relationship and a placid transition. Unlike FDR, Obama has not seemed concerned that some of his predecessor’s unpopularity might be catching. Although their inaugural transitions seem practically opposites, both FDR and Obama were greeted with historic popular enthusiasm and an optimistic sigh of relief -- in Obama’s case, worldwide. But the failing economy was only one component in George W. Bush’s quagmire of international infamy. In contrast, public enmity toward Hoover took root in nearly four years of accumulating economic misery. In 1929 unemployment was 3%. By the time of FDR’s inauguration in 1933 25% of the work force was unemployed and another 25% underemployed. The crisis had grown so acute that FDR had to order a halt to all financial transactions on his first full day in office. But ultimately it was grassroots action that pushed the New Deal forward. With President Obama’s inauguration hopes seem high that bipartisan efforts can avert acute social desperation like that of 1933. But still, the world economy falters. State and local government and public school programs grow insolvent. Unemployment worsens. The banking crisis remains unresolved. Could we again find ourselves confronting social anguish like that of 1933, our communities hurting in a way that something has simply got to give? If the center will not hold, how will Obama respond? Will he remain cautious? Or will he throw caution to the wind and break with bipartisan consensus, as FDR once did? When we reflect upon Bush’s unpopularity and what we learned from FDR and Hoover before him, what matters most will take place at the grassroots. Andrew D. Coates, MD, secretary of the capital district chapter of Physicians for a National Health Program (pnhp.org), teaches medical students and residents at Albany Medical College and practices internal medicine in Albany, NY. 1/12/09: The Gurney in the Hall Not too long ago, on duty at the hospital, I was called to the emergency room to see a patient, perform a history and physical and establish an initial plan of care. The patient couldn’t be sent home. Busy, the emergency room needed him to move upstairs soon. Across the counters and computer terminals, past the idle equipment, the laundry carts and crash carts, the rolling gurneys, the scene, to the untrained eye, would appear chaotic. For those of us able to explain the role of each scurrying player one by one, the emergency room seemed pleasantly busy, far from a frantic, as it sometimes gets. When too many demands pour in, emergency room caregivers harden, grow brusk, demoralized and cynical, buoyed only by gallows humor. This night was nothing like that. The ER staff would go home tired but proud of their service to others, not demoralized or burned out. Still my interview and physical exam took place at a gurney in the corridor. The bed even had a room designation, a sign on the wall above it that read something like “Hall A#2.” I pulled up a stool, in order to talk in depth with my patient, seated on his bed in the hall. Every 30 seconds or so passers-by brushed past, just behind me or even between the patient and I. Every few minutes I had to pick up my stool to move out of the way of hospital transporter pushing a gurney or a wheelchair, some with patients. My patient was a good sport. He put up with the hallway. He didn’t want to take up space that might help another patient – or disrupt the care of others. In other words, although ill in the emergency room, he retained his humanity. Many patients await gurneys in the hallway across the United States. This winter newspapers have reported a dramatic increase in visits to emergency rooms by patients without insurance, thanks to the crisis in the economy. And the Centers for Disease Control reported that over the last decade ER visits climbed more than 32 percent. Meanwhile the number of hospital emergency departments declined by more than 10 percent. No wonder the emergency room routinely looks like chaos. Because hospitals often lack sufficient inpatient beds, and because the hospital staffs the minimum, not the maximum, number of nurses, the emergency room can get swamped. This is not because of healthy patients abusing the system. What happens are bottlenecks in the flow of patients. A critically ill patient or an unstable mentally ill patient can tie up an emergency room bed, its nurse and staff, for hours, waiting to be transferred to the floor, or to another hospital, starting a cascade that leads to long wait times. As a matter of fact a study last year by Dr. Andrew Wilper and other Harvard researchers showed that in 1997 heart attack patients waited 8 minutes for treatment in the emergency room, but in 2004 waited 20 minutes, on average. By 2004, 25% of the patients with acute heart attacks in the ER waited 50 minutes or more. An emergency room can grow so busy that it has to refuse ambulances -- something called "diversion." When ambulances are re-directed to another hospital it increases the risk of death for emergency patients who are critically ill. The Institute of Medicine estimated that in 2003 there were 500,000 ambulance diversions. Somewhere in America an ambulance is diverted on to another, less crowded emergency room, about once every minute. When the demand for beds surges beyond the gurneys in the hall -- the strain upon the staff grows intense: human tragedy and suffering, up close and in great quantity, met with insufficient resources. But here we were in an emergency room not swamped – chaotic but designed to be busy, with the patient on his way to the floor. As he went upstairs I considered the empty hall and the lonely stool, left behind. The gurney in the hallway might seem normal in a place where scurrying and controlled chaos are expected. Patients and caregivers routinely take it in stride, maintaining their dignity in an undignified setting. But when an unexpected surge in patient volumes threatens the system, we need the resources to protect our common humanity, our dignity and privacy. It is time we used our nation’s vast resources to restore so dignity to our health system. Our emergency room needs resources to take the gurney out of the hallway. It needs doctors, nurses and staff. It needs proper exam rooms. To restore privacy and dignity to our health system we need single- payer national health insurance, along the lines of Congressional Bill HR 676. Andrew D. Coates, MD, secretary of the capital district chapter of Physicians for a National Health Program (pnhp.org), teaches medical students and residents at Albany Medical College and practices internal medicine in Albany, NY. 12/26/08: When September Ends Ten years ago this month I was new doctor, an intern doing primary care in a rural village here in the WAMC listening area. It was an ideas letting to learn to become a doctor. A farmer came in with a productive cough, fevers, shortness of breath. He looked ill. I listened to his lungs and heard rales in a one lobe. Pneumonia. Did this many need to be admitted to the hospital? I double checked his vital signs, took a sputum sample for culture, drew blood and sent him up the hill to the community hospital for a chest x-ray. It was an amazing experience to be new physician, to place my new skills at the service of another person. As it turned out, the patient’s tests were mostly reassuring. His x- ray was not too bad, his blood tests not too bad. He had acute bronchitis, possibly viral. But still I worried that this could become a frank case of bacterial pneumonia. I wrote a prescription for the drug I thought most likely to help his body expel the infection. I asked to see him again in a week or so, sooner if necessary. Medical school and my first months as an intern had taught me about community-acquired pneumonia and how to treat it. To share this knowledge was liberating — we knew which antibiotic would best treat this infection. The patient returned the next week to say he was feeling better. He gently explained to me that he could not afford the drug I had chosen. It had cost more than his usual spending money for an entire month. It had cut into his budget for food and gasoline and electricity. With some anguish I discussed this with the doctors supervising me, my teachers and mentors. How do we learn how much each drug costs? When is the lecture on which antibiotics are both affordable and appropriate for the diagnosis? How do we know how the patient will pay for their care? Isn’t it immoral to ask? Why does medical education stress state of the art science if the ability to pay trumps our ability to practice the same state of the art medicine? Thus I learned about the bottom line — the bottom line of the chart sticker. It had a code that one could easily decipher. It told who was paying the bill — which insurance company, or HMO, or Medicare, or Medicaid, or “self-pay” — uninsured. Soon I found myself checking that bottom line for every patient — and when I learned to raise the issue tactfully, respectfully. I learned that out-of-pocket costs threaten financial disaster for nearly all patients, regardless of insurance status. My teachers soon taught me a few tricks. For example many medications cost roughly the same amount per pill even though there might be several strengths to choose from. If a pill could be cut in half we might prescribe a double dose and instruct the patient to take half a pill instead of a whole. By cutting the pill in half, patients could cut the cost in half too. I then learned from patients that they did this already -- but took half the prescribed dose. They would cut the tablet or take one every other day -- because of the expense! None of us went to medical school to ask our patients to choose between an antibiotic and the electric bill. But when we look back over ten years, we shudder. The appalling and insidious intrusion of the questions — “who will pay?” and “what is the cost?” — accelerates, undermining our ability to practice medicine, poisoning the doctor-patient relationship. What it to be done? It is time to acknowledge that employer-based private health insurance has failed our nation. Excellent data confirms our experience that co-pays, deductibles and co-insurance payments lead patients to delay or avoid the care they need. The only proposal on the table that will eliminate these demands for money from the doctor-patient relationship is single payer, or national health insurance. A single-payer program would provide a socially responsible way to cover the costs of all necessary medical care for all inhabitants of the United States. It would center on care, not coverage and not costs. Care. It would have no co-pays, no deductibles, no additional out-of-pocket costs for needed care. Single-payer health reform will take and important step in helping to heal the doctor-patient relationship. But it is also the least we should expect from a great democracy. For the sake of our common dignity, it is time we guaranteed that all necessary medical care will be provided to all who need it. We need a single payer system. Andrew D. Coates, MD, secretary of the capital district chapter of Physicians for a National Health Program (pnhp.org), teaches medical students and residents at Albany Medical College and practices internal medicine in Albany, NY. |
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